Background• We had… • documented delays in recognition & treatment of sepsis contributing to patient harm • tried this once before and failed (2008)• We knew implementing the sepsis bundle was the right thing to do because… • early recognition and intervention leads to better patient outcomes • improvement bundles work • it is important for our patients, our agency and to PHSA (Included in the 11/12 Strategic Action Plan).
Problem StatementLack of standardized recognition, communication of findingsand response to sepsis have lead to long lead-times fromrecognition to response and have caused patient harm
Primary Objective & Key Measure• Primary objective: – To implement an internationally-recognized sepsis screening tool and treatment protocol.• Key measure: – Documented timely screening of appropriate patient population and where required, timeliness of medical intervention.
Recognition PDSA Cycles• Problem: – No standard work• Idea: – Standardize screening process throughout the BCCH • When to screen • Who to screen • How to screen• PDSA cycles – 14 (& counting) – Testing of screening tool for value added • Relevance to patient population balanced with: – time to complete – frequency of use = time vs benefit – Readability – Standard work instructions within screening tool – Alignment of screening with existing processes/tools Recognize - Respond - Refer
Aligned with ED Triage and Initial Assessment• Andon for screening on electronic patient tracking board (to be developed)• Combined sepsis screening tool with RN assess form (to be developed) Recognize - Respond - Refer
Aligned EoPC with Sepsis Screen in Inpatient Areas Recognize - Respond - Refer
Aligned with Fever & Neutropenia Guidelines • Bloodwork standardized • Inclusion of fever & neutropenia antibiotic protocol into sepsis bundle • Adaptation of screening tool to reflect oncology patient & referral process Recognize - Respond - Refer
Aligned with PICU “Purple Sheet”• Highlight WBC trends as indicator for sepsis screening Recognize - Respond - Refer
Result Recognize PDSA Cycles• Standard work for screening New Admission to Unit (Including who, when & how) Screen for Sepsis New Patients Existing Patients Monitor and Assess NO Increase in EoPC Score YES Screened Positive (+) for Acute Organ Dysfunction NO YES Screen for Sepsis Follow escalation of patient care protocol Recognize - Respond - Refer
PDSA Cycles with Response • Problem: – No standard escalation process or response upon suspicion of sepsis. • Idea: – Standardize response process and treatment • PDSA – Aligned with EoPC process for monitoring and accessing supports Recognize - Respond - Refer
PDSA Cycles with Response • PDSA (con’t) – “Suspected Sepsis” order set & Algorithm (Final testing) – Incorporated audit components (Order time, receipt time, delivery time) – “Critical Care Sepsis” order set & Algorithm Recognize - Respond - Refer
PDSA Cycles with Refer• Problem: – No standard work for referring patients• Idea: – Aligned with EoPC process• PDSA: – Reinforcement of existing escalation processes. – Highlight supports and screening prompts with First Responders, CTU residents and PICU team Recognize - Respond - Refer
Results of Kaizen Events X X DELAY INCONSISTENTPatient Condition Worsens X DELAY Recognition of deterioration by “someone” Assistance sought Management by most appropriate resources Relocation to appropriate care area if required X XX X INCONSISTENT DELAY Medical Intervention INCONSISTENT DELAY
Follow On Six units developed detailed Action Plans. Some examples:• All areas: – Ongoing measurement – Update communication plan – Living PDSA cycle collectively (8 month timeframe) – Physician order sets have been approved and are available for use• ED: – Update documentation • Incorporate sepsis screening – Further defined measurement process – Implement Status Board andon• PICU: – Test critical care algorithm and order set• Oncology: – Updated Fever & Neutropenia order sets.
Accomplishments• Recognize: – Screening tool as part of standard work – Highlighted usefulness of existing processes and tools in screening process – Strengthened existing processes/tools• Respond: – Initial resuscitation order set & algorithm redesigned & in use – Critical care order set & algorithm designed & are available for use• Refer: – Clarification with PICU re: role in screening
Lessons Learned• Surprises – 75% of areas liked “it” – Value of standardization – Linkages between other processes – EoPC documentation patterns – Number of changes hitting staff at once• Highlighted for next time – Communication (more & targeted) – Assessment of organizational readiness (e.g., upcoming changes and resources available to be successful)
Audit Plan• Question: Screening for sepsis at appropriate times• Question: Timeliness of response upon (+) screen
References• Brierley J, Carcillo JA, Choong K et al. (2009). Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Critical Care Medicine. 37, 666-688.• Cruz AT et al. (2011). Implementation of goal-directed therapy for children with suspected sepsis in the emergency department. Pediatrics; 127: 3 e758-766.• Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R et al. (2008). Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine. 36, 296-327.• Goldstein B, Giroir B, Randolph A. (2005). International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr. Critical Care Medicine. 6(1):2-8.
Contact InformationDeb Scott RN BScNProfessional Practice LeaderBC Children’s Hospitaldscott6@cw.bc.ca604-875-3059Jamie LepardFacilitator, imPROVEProvincial Health Services Authorityjlepard@cw.bc.ca604-916-5795